Gail Smith, Rn Email & Phone Number

United States

Linthicum Heights, Maryland, United States

Facilitated interdisciplinary collaboration and care continuity across care settings and systems; empowered the patient/member and/or caregiver to play an active and informed role in post-hospitalization care plan execution. On average, served 50 cases monthly.• Partnered with high risk members to assist with unmet needs, helped resolve barriers, and provided supportive service• Collaborated with Utilization Management teams to determine patient (member) status and appropriate discharge plan• Identified concerns and problems and established relationships with practitioners after discharge from hospital stay• Resolved issues in transition from hospital or skilled nursing facility (SNF) to home. Encouraged development of self-management skills and offered effective member-provider communications to ensure a smooth and successful post-acute care discharge• Increased member satisfaction by resolving care and social issues• Created cost savings; helped members resolve care barriers, addressed chronic issues by providing high-quality, patient-centered care which prevented avoidable re-admissions and managed efficient resource utilization• Coordinated with the individual and/or caregiver to identify biggest health concern(s) and immediate goals for recovery and coached the individual through all Four Pillars® Care Transitions Intervention

Linthicum Heights, Maryland, United States

Identified potential candidates for REM, secured and reviewed documentation, completed application process, and coordinated case management with physicians/doctors.• Generated cost savings for Maryland Physicians Care by enrolling qualified high cost members to the State of Maryland REM Program• Researched clinical information available to find documentation of REM eligible diagnosis or obtained medical records from specialists and hospitals to provide necessary documentation• Educated potential REM members regarding voluntary REM program and provided knowledge of resources and benefits to encourage enrollment• Partnered with specialists completing REM application, reviewed documentation for appropriate clinical information• Increased member satisfaction, resolved treatment or care issues prior to transition to REM• Collaborated with the REM Program Intake team to enroll members

Linthicum Heights, Maryland, United States

Provided care coordination services to a group of complex, special needs pediatric patients and families across the continuum of care; worked with parents of children to assist in resolving care or treatment issues.• Assessed, planned, implemented, coordinated, and evaluated the plan of care in partnership with the family and other members of the health care team• Assured necessary education and support; assisted parents with resources and learning tools to obtain necessary/appropriate care• Provided supportive care to member's and parents and encouraged them to be compliant with care• Coordinated with member's parents to link to financial and other support agencies in the community